A one-year old Simulation : Keep Walking

Yesterday Wed 29 Aug 2555, it was the first cerebration for us that we have taught medical students with simulation scenerio for a complete year. It was started on group 13 of last academic year. Therefore yesterday was the first group of the second year.

Although we are in the process of gaining experience in teaching with this method, we hope that the Faculty of Medicine Siriraj Hospital will start more simulation cases in the very near future. Although practising medicine in the Kingdom is not difficult as in the western more developed world, but with the advancement of ICT, patients and people are doing their research to find where they should head to in order to treat them, and they may apply for lawsuit in the case that complications have happened.

Simulation will definitely help medical students to gain experience in difficult case management, they have to make a decision in a simulated limited time, they have to help each other for a dynamic team management,

Anaesthesia for Healthy patients 2

As we mentioned in the previous post upon the healthy patients requiring some surgical procedures, now it is actually not only the true healthy patients who can be categorised as healthy. If your patients belong to ASA Physical Status 2-3, they can fit this class as well.

It means that stable long term patients can be scheduled for anaesthesia as their healthy counterparts, however when dealing with this patient group you have to meet them, prepare them, and manage them about the concurrent medications. You have to give them about information on pharmacology which drugs they should take or which to omit on the day of surgery.

On pain control in the postoperative period, multiple drug classess can be applied, not only opioids and local anaesthetics.

About the safety, one common thing is usually that we may give the level of care less than that of high severity  patients, therefore, the morbidity is much higher in this healthy patient group, because we may think that everything will be fine/ all right which leads us to complications.

Medical ethics & Formative Evaluation

We have taught our medical students some insights about medical ethics from anaesthesist's point of views. The principles are mainly adapted from the Belmont report which is worldwide recognised in the USA. It includes the principles of respect of persons, beneficiance, and justice.

You should respect every single patient in front of you the best appropriate way, for example; continuous ECG electrodes you should be careful not to expose your patient 's body too much, if you just would love to know the cardiac rhythm you can place the electrode on the shoulders and leg, not have to expose your patient's chest. Religion is a highly sensitive issue, you do have to realise that and keep your management according to that. Secret or confidentiality is always a secret, do not have to share or tell somebody else what your patient has.

You must weigh the risk and benefit, first, before performing and giving your patient care, if you have calculated that the risk is far less than that of better patient benefit, so you should proceed that. Conflict of interest is also a topic that you have to concern.

For the fairness and justice; the standard of care should be only one standard, not the double trouble.

We also ask our medical students about the Organisation culture, the motto, the vision or whatever the institute thinks or believes in and try at the very best to achieve. 

        S = Seniority,  I = Integrity, R = Responsibility,                         I = Innovation
        R = Respect, A = Altrulism, J = Journey to Excellence and                                             Sustainablity 

The example of power of Facebook is shown here, you should not discuss your patient over the world wide web, because you are not keeping your patient's only secret. How could you discuss your pregnant lady underwent emergency caesarean procedure here! How could you???

After the medical ethics is discussed, we talk with our medical student on the formative evaluation at the mid-rotation period. We discuss the requirement for new medical graduates by the Thai Medical Council. Some skills are important and they should pay their attention to.

The Figure below is for Department of Anesthesiology at the mid-rotation feedback form, we got this form from UWSMPH, University of Wisconsin School of Medicine and Public Health.

Surgical Critical Care @ the Critical Time

Surgical critical care and other critical care specialties have their own limits, the art of Intensive care medicine or Critical care medicine has to be available within its golden window period in order to correct the pathophysiology on time and save our patients' lives. We must try to offer our best service available to help them on time otherwise time is running out and moving fast!

For example, the antibiotics administration for septic patients has been show that if you can give such drug at the earlier time, the better outcome of your patient will be. Some ICU policy even states that they will audit the giving time of antimicrobials after they just ordered, the appropriate time will be within two hours, the later time you give, the higher risk of death of your patient will become.

So, what the critical time means, it would mean that you patient is getting worse, he may show signs of organ dysfunction, if you can detect such problems at the earliest possible time, you can divert the patient's fate that  can save his/her life, however, if the other way occurs, you are not sure what has happened to the patient, without effective and enough interventions you have performed, you have already delayed the best treatment that he/she really needs at that time, the running of damaging process is still going on, at the time you can notice/ recognise the real situation that might be too late to get your patient back on track.

This critical time is so important you should never have missed it, because it, the pathology, has been taking place for a while before it will show you the severe clinical presentation. You do have to carefully review a throughout history after you have managed the priority lists for your patient.

For the sake of your patient's safety, act smart and wisely at the critical time!

Postoperative Neurological Complications

When you have to examine your new postoperative patients transferred to you at the Surgical ICU, you have to evaluate him from head to toe. Not only the physical examination, you have to ask the relevant essential information from the medical team who took care of your patient before handing him/her to you as well. After you have all the important informations, you then can make an SICU plan for your patient, what the diagnosis would be, which priority you have to look for and get rid of first, and what interventions your patient is really need at the moment.

At the moment we have a previously healthy young man delivered to us at the SICU after an emergency abdominal procedure, the main problem besides sepsis is we cannot wake him up, he did not respond to voice, deep pain, and had lost important brainstem reflexes. After a long period behind last dose of anaesthetics and opioid for acute pain control, he still suffered from prolonged emergence which should not belong to the anaesthetics effects, a throughout neurological examination was performed, and we made a conclusion that he need an emergency CT scan of his brain. Because he had the problem of azotaemia, so we asked for non-contrast CT brain, however, we did not see any important cerebral pathology from that test.

Today is 72 hours after his anaesthetics, he seems to be better than he was, some brainstem reflexes have gained responses, he can open his eye from voice, however, he still have some fluctuation in his consciousness. We have some more details of his history from his wife and mom about heavy alcoholic consumption, hopefully, it will help us to better rescue him from this sleep.

2000 Hit 2Day ^.^, So who are you any way?

After a touch of 1000 hits in June, it takes approximately two more months for another 1000 hits. We are just curious about who our readers are. Are you actually the medical students or you are here just by chance from the Google Chrome page!

Please give us your voices or your comments about where about your really are from this planet and who you are, looking forwards to hearing from the readers!

Working with an Elective Med Student

At the moment there is a med student from the UK being with us, he is from Penzance/ Exeter School, he has applied to work with us for a month long at the Surgical ICU, and working in the operating theatres as well (general, CVT! and paediatrics).

We discussed about the skills required for the new graduate doctors by the Thai Medical Council, after we had performed a spinal anaesthesia for an old lady scheduled for venous strippling, although spinal anaesthesia is a grade 4 skill meaning that a medical graduate has seen this skill or has helped during their undergraduate education or the three year working for more experience, however, the lumbar puncture is a must skill for an MD or he/she must be able to perform it.

We talked about monitoring for a healthy patient underwent a laparoscopic nephrectomy to donate her kidney to her daughter, we did not mention the choice of anaesthetics, but we just talked about how an anaesthetist thought about giving anaesthetics, about the position; what position she would be placed, and then which arm for what; an iv line or an NIBP cuff.

We also discussed about the administration of a muscle relaxant, he mentioned that the patient had a movement after an LMA placed during the surgical team scrubbing the operating site. However, we concluded that it was from the depth of anaesthesia that we should focus on not the movement of our patient, and also it may be too easy just giving a muscle relaxant to stop or eliminate the patient's move, but you have to realise that it is not the anaesthetic agent at all. It does not help reduce the pain, make him sleep or increase the anaesthetic depth.

Today Update: a small chat with him

He enjoyed his time working in the Acute pain service, and he had wonderful experience observing a patient requiring electroconvulsive therapy, tonic clonic convulsion. One psychiatric patient had the difficulty peripheral venous access need approximately 15 times!

He pretty much missed this good time at the surgical ICU, we discussed about the different world of anaesthesia from Preop. clinic to OR to ICU, and there is also pain clinic waiting for him to enjoy.

No More Borders ! Learning with Clinical Presentation

Many medical schools are teaching with departmental based style, meaning that everything the medical students should learn is governed by each department, this rule is also applied in our Faculty. However, many has adopted the PBL principles which means that the topics chosen to the medical students is guided by multi-disciplinary curriculum, because consultants from many departments can join together to teach the same topic.

The same principle applied to Clinical Presentation curriculum, compared to the PBL case discussion, learning with the clinical presentation or can be called "symptomatology" can lead to fewer case numbers for the same learning objectives, and the teachers are from different specialties as well.

So, the students have to be ready and get more involved in this teaching module, because it is definitely from the structure feeding style from each separate department, it will enhance the thinking, reasoning, and communicating skills to the learners that require for the 21st century life.

For example, a man with headache does not mean that he should belong to neurology and neurosurgery units only, he may just need an ophthalmoscope for his eye examination, if he has just been given anasthetic to his subarachnoid space, he then needs a shout to his anaesthetic consultant for a post-dural puncture headache to be ruled out. One more example; Dyspnoea does not mean that he needs a chest physician to treat, he may require a cardiologist, an ENT man, or even a CVT surgeon!

Updated on 5 Sept 55:
We discussed this topic with a group of medical students working at the GI Endoscope centre, there was a lady presented to us with a problem of dyspnoea, she had been diagnosed of congestive heart failure (or more specific Left sided heart failure), and also had a problem of her chest. She told us that she had a problem of collapsed lung but cannot recall which side it was. So, in this patient, the symptom of dyspnoea is from both the cardiovascular and respiratory in origin.

The problem of anaemia is also a problem of multi-disciplinary medicine, your patient can have a problem from the haematologic system, the bone marrow or anything that interferes the red cell production, your patient can have a problem of blood loss from the GI tract either upper or lower site, he/she can present with a haematuria which is urinary system, or anemia can be derived from the renal cause because your patient develops kidney dysfunction.

Undergraduate Education Stategies with Action Plans

Since two years ago Professor Jariya Lertarkayamanee has led the department, she has applied the Thai Quality Criteria to every service unit from operating room service to education to research, and even in the department office.

For the education unit, we have three major teams; one for medical student, while the other two are post-graduate team for residency training and nurse anaesthetist trainee each. We have gathered to put the main objectives for all three teams together but the action plan and those who are responsible for the team are separated.

The goals for education team are as follow
1. The Curriculum has to be up-to-date, and the learners must be happy and smart and competent
2. The support team must be ready as well such as the video, e-learning, the official/ secretary on the job
3. The academic research from the education team

What we have done to improve our course to suit 5th year medical students are as follow:
1. We have change the topic of lecture and add new cases for discussion, bring in some easier cases and keep the more difficult case for consultant to discuss with the learners in the OR. We move a bold step with inducing a simulation teaching into the course, we apply the technique for the subject of complications of anaesthesia instead of lecture we change it to simulation platform.

2. We encourage our medical student to learn from new media, although our team has a facebook page but it is not really formal, some topic has beautiful video clips on youtube, and some topics can be up on the faculty e-learning page, but need some time to finish that. We have already started a book for medical students project, the editorial process is now on. Hopefully we can finish this project on time for the next academic year.

3. The result of a Pretest-Posttest has just been analysed, we will sit down and write something about it.

An LMA : a Laryngeal Mask Airway

An LMA is now a very popular airway equipment in use in the anaesthesia and emergency medicine world. It can offer less stress response in the patient, is considered as an airway alternative to an endotracheal tube, and can be an option when the difficult airway management either ventilation or intubation may be encountered.

In the United Kingdom, anaesthesia trainees have to share their experiences in the placement of LMA with the paramedics trainees, because the latter group has to practice and manage the airway as the primary personnel sometimes at the scene, they also have to log their experiences for their certified examination.

The following are the sequences of putting an LMA to the right position, the patient has suffered airway difficulty because of his job before the accident was an official working at the Electricity Generating Authority of the Kingdom.

An LMA sometimes comes from a Loss of My Airway, it depends on whose hands that use the equipment to place it in the most proper position, otherwise you cannot put it in and traumatise the airway or it may become partially airway obstruction or in the worst case of all : you cannot ventilate your patient with it.

Drug Interactions

Anaesthetics is a good example of multiple drug therapy, because from premedications of your patient until he/she is transferred out of the OR, they will definitely be administered nearly 10 drugs for general anaesthetics. In other patients when you decide to give your patients a multiple pharmacologic regimen, you do have to weigh the benefits of doing so against the risk of what would happen after doing so. Normally, it  approximately happens around 3-5% but will dramatically increase to 20% if there are more than 10 drugs administered for him.

Therefore, when you consider to use multidrug regimen for your patient, you have to recalculate the dose of each drug while the combined drug would have a well-maintained effectiveness. One thing has to be kept in mind would be when you include the drug which has a narrow therapeutic index; such as digoxin, you have to use with caution because it would create this drug interactions more easily.

Patients at risk for the development of drug interaction are obesity because their tissues are increased and their hepatic enzyme function is altered as well, the patients having organ transplantation with immunosuppressive agents in place, the HIV positive patients who are receiving antiretroviral agent; reverse transcriptase inhibitors because these organ transplant and HIV patients the added drug will have inhibitory effects on the function of CYP, cytochrome P450 activity, therefore the other drugs metabolised by the inhibited enzymes would create drug overdosage then toxicity would arise. Besides these patient groups, patients with an infection or sepsis are prone to develop this problem as well because the enzyme CYP activity is also depressed during infection.

A Shared airway 2: the sequences

In the ENT theatre, as we have mentioned you before that we have to manage the airway with the ENT personnel they can examine the pathology while the patient is apneoa, or we can ventilate the patient either by the face mask, via the side port of the rigid bronchoscope or sometimes we can use the jet ventilation equipment for the microlaryngeal procedure.

Yesterday there was a patient presented to us for her tracehal reconstruction, we had to alternately ventilate the patient via facemask and the rigid bronchoscope before we had a definite endotracheal tube noncuff placed in the trachea which is considered quite normal for the paediatric patients not the adult size patient.